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Thank you for giving me the opportunity to supplement the comments of Reggiani Bonetti et al1 regarding our systematic review of the pattern of lymph node (LN) metastases in colon cancer.2 They present interesting numbers of microskip lesions in the mesenteric root close to the paraaortic LN in T2 to T3 colon cancers. Unfortunately, they do not describe the location of the lesions, because these would be considered as distant metastases in right-sided cancer, where the superior mesenteric vessels define the mesenteric root. Their findings confirm their previous report on LN micrometastases in stage I colorectal cancer3 and add support to the plausible explanation for improved oncological outcome after complete mesocolic excision for stage I to II colon cancer compared with conventional colon cancer surgery (noncomplete mesocolic excision).4 Surprisingly, we found the numbers needed to treat to be only 10 and 7 for stages I and II to reduce the risk of recurrence during the first 4 years after resection.4 There was no indication of upstaging because of differences in the pathology service between the participating centers or from the more extensive LN dissection. The standard procedure of cutting the isolated LNs in half and examining only a few representative sections per LN for detecting LN metastases was used. This presents a risk of understaging in daily clinical practice.3 The pathologist in our study might have missed some mesocolic LN micrometastases in patients at stage I to II. In patients with similar tumor characteristics undergoing noncomplete mesocolic excision, these micrometastases would not be included in the resected specimen and may subsequently have caused the observed increased risk of recurrence after noncomplete mesocolic excision surgery. A meticulous standard histopathology assessment2,3 would provide us with a more accurate estimate of the true stage but appears to not be possible in daily clinical practice.
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